Form for submitting information to the Special Rapporteur on
contemporary forms of slavery, including its causes and
consequences
1. IDENTITY OF THE PERSON OR INSTITUTION SUBMITTING THIS
FORM (This information will remain confidential).
(a) Name of person/organization
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Family Name:
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First Name:
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Name and type of organization (if any):
(b) Relationship to victim (s)
(c) Address:
(d) Contact details (please indicate country and area code)
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Fax:
Tel:
e-mail:
website:
2. ALLEGED INCIDENT
I. General information
-Does the incident involve an individual or a group?
-If it involves a group please state the number of people involved and the
characteristics of the group:
II. Information about the victim(s):
(a) Name:
(b) Sex:
(c) Date of Birth or Age (at the time of the incident)
(d)Nationality:
(e)Occupation:
(f) Ethnic / religious / social background, if relevant:
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(g)Address:
(h) Other relevant information:
(i) Has the victim(s) given you her consent to send this communication on his or her
behalf? Please make sure you obtain the victim’s consent, whenever possible
(j) Has the victim(s) been informed that, if the Special Rapporteur decides to take
action on his or her behalf, a letter concerning what happened to him or her will be
sent to the authorities?
(k) Is the victim(s) aware that, if this communication is taken up, a summary of what
happened to him/her will appear in a public report of the Special Rapporteur?
(l) Would the victim(s) prefer that her full name or merely her initials appear in the
public report of the Special Rapporteur?
III. Information regarding the incident:
(a) Detailed description of human rights violation:
(b) Date:
(c) Time:
(d) Location (town and country or countries):
(e) Number of perpetrators:
(f) Are the perpetrator(s) known or related to the victim? If so, how?
(g) Name or nickname of perpetrator(s) and information about their identity
(description, scars or body marks such as tattoos, clothes/uniform worn, title/status,
vehicle used):
(h) Does the victim believe she was specifically targeted because of her race, age, or
gender? If yes, why?
(i)If there are witnesses to the incident, indicate their names, age, relationship and
contact address. If they wish to remain anonymous, indicate if they are relatives, bypassers, etc.; if there is evidence, please specify.
(j) Has the victim(s) seen a doctor after the incident took place? Are there any medical
certificates/notes relating to the incident concerned?
IV.
Information regarding the alleged perpetrators
(a) Was the violation committed by private individuals or groups (rather than
government officials)? If so, include any information which might indicate that the
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Government failed to exercise due diligence to prevent, investigate, punish, and
ensure compensation for the violations.
(b) If it is unclear whether they were state or non-state agents, please explain why.
(c) If the perpetrators are believed to be State-agents, please specify (military, police,
agents of security services, unit to which they belong, rank and functions, etc.), and
indicate why they are believed to be responsible; be as precise as possible.
(d) If identification as State agents is not possible, do you believe that Government
authorities or persons linked to them, are responsible for the incident, why?
V. Steps taken by the victim, his/her family or anyone else on his/her behalf
(a) Has the incident been reported to the relevant State authorities? Indicate if
complaints have been filed, when, by whom, and before which State authorities or
competent bodies (i.e, police, prosecutor, court)
(b) Have the State authorities taken any action after the incident?
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If so, which State authorities?
What action did they take?
When did they take this action (date and time)?
VI. Laws or policies which are or are likely to cause or contribute to this
particular human rights violation
If your submission concerns a law or policy, please summarize it and the effects of its
implementation on human rights. Provide concrete examples, when available.
In this regard, in order to carry out her work regarding root causes of violations, the
Special Rapporteur is interested in receiving information and/or texts of draft laws
relating to or affecting human rights, as they relate to the mandate in question, in
particular regarding the issues listed above in the section “"What are some examples
of specific issues that fall under the competence of the Special Rapporteur?”
The Special Rapporteur on contemporary forms of slavery would be interested in
receiving information on national or regional laws or policies relating to prevention,
prosecution or rehabilitation of victims of violations relevant to her mandate. The
Special Rapporteur would also be interested in receiving information about laws or
policies which are discriminatory or are discriminatory in their application (eg. on the
grounds of ethnicity, nationality, descent and sex); or laws or policies which relate to
the rights of the child, for example in relation to child labour.
Please inform the Special Rapporteur of any further information which becomes
available after you have submitted this form, including if your concern has been
adequately addressed, or a final outcome has been determined in an investigation or
trial, or an action which was planned or threatened has been carried out.
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Date
Signature of author
Please return by fax to +41 22 917 90 06, by e-mail to urgent-action@ohchr.org ,
srslavery@ohchr.org or by postal mail to:
THE SPECIAL RAPPORTEUR ON CONTEMPORARY FORMS OF SLAVERY
SPECIAL PROCEDURES DIVISION
OFFICE OF THE HIGH COMMISSIONER FOR HUMAN RIGHTS,
OHCHR-UNOG, 1211 GENEVA 10, SWITZERLAND
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